On January 11, The Century Foundation hosted Health Reform 2020, the first conference of its kind to explore proposals to leverage public programs to improve affordable, quality coverage. Leading experts from across the country convened in Washington, D.C. to discuss the path forward for health care reform leading into the 2020 presidential election, including the opportunities and pitfalls of different public plan options and reform proposals. The discussion, which can be seen here, was grounded by articles published in the January issue of The American Prospect that outlined approaches to expand Medicare, Medicaid, and hybrid options. The discussants explored the topic of reform from three different angles.

First, the public plan debate was contextualized by looking at its past, present, and future.

Paul Starr, co-editor of The American Prospect, reviewed the history of health reform, reminding us that, “Every major progressive health program in the United States was developed on the rebound from earlier setbacks….”

Anna Greenberg, a public opinion expert, illustrated how the attacks on the Affordable Care Act (ACA) and existing coverage in the past year have increased support for reform. Her remarks included the recent finding that 47 percent of Americans now support a government-run health system.

And Anita Dunn, a strategist who worked for President Obama during the passage of the ACA, said we are in a “good place” for this next round of reform. After reviewing the lessons learned, she concluded: “The goal of universal coverage—lifetime quality care …—is shared; the policy differences will be debated, but communicating about it in ways that will resonate with the people who are going to be covered is critical….”

After that discussion, three health policy experts offered analytic perspectives on how best to develop, sequence, and understand public plan options.

Sherry Glied, dean of New York University’s Robert F. Wagner Graduate School of Public Service, urged the development of additional options, given that health policy is a “highly iterative process.” “What we need now,” she said, “[are] more policy options so that, when our bills hit constraints, we have something to go back to, and more cohesion around the goals we want to pursue.”

Jeanne Lambrew, TCF senior fellow, discussed the benefits and challenges of the various starting places for expansion—private insurance gaps, age, need, or choice—and suggested that “these matter because starting in the wrong place could lead to retrenchment or backlash, and even the best-planned phase-in may stall, as has happened historically.”

And Larry Levitt, senior vice president at the Henry J. Kaiser Family Foundation, took a hard look at what exactly a “public plan” is, or what Sherry Glied called “publicness” when examining options. He suggested three challenges for policy makers: making plans “simple,” “sustainable (politically and financially),” and “not scary.”

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Third, specific ideas were presented, debated, and compared by academic experts, state regulators, and reporters. These ideas included:

Medicare-Based Options: The rapid rise of the Medicare for All proposal has moved Medicare-for-More proposals into the limelight. We heard:

Georges Benjamin, CEO of the American Public Health Association, on the issue of feasibility, said, “It would be a challenge, …but at some point, people are going [to get] tired of paying too much for too little, and when they do that, Medicare for All is there.”

Cathy Hurwit, chief of staff to Rep. Schakowsky (D-IL), explained a Medicare Part E proposal which would give Americans a choice of Medicare: while it would have “multiple sources of care, we would have single rules going across those payers… based, again, on Medicare.” She urged “building on the public acknowledgement, awareness, and willingness and eagerness to be involved in this fight.”

Paul Starr noted that the last two Democratic presidents who supported health reform lost control of Congress in the midterms, predicting, “I don’t think the next president will risk his presidency, or her presidency, …on health care.” He suggested, “We need to figure out a strategy that is more feasible, politically and fiscally,” such as his MidLife Medicare proposal, which would lower Medicare’s age eligibility to fifty.

Hannah Neprash, a professor of health policy, parsed the Medicare proposals along multiple dimensions, including their size. To illustrate this, she provided an approximation that extending Medicare to people ages fifty to sixty-four without employer-based insurance would increase Medicare enrollment by 20 percent, “whereas, the other end of the spectrum, if you move everyone into Medicare, is basically a five-fold increase in the size of the program.”

Medicaid-and State-Based Options: The successful defense of Medicaid during last year’s repeal-and-replace debate helped catapult this program as an option to the forefront of the broader health reform debate. Two academics, a former state official, and a current state official explored various options.

Michael Sparer, a professor of health policy, made the case for states allowing all residents to buy into Medicaid: he said, “Medicaid offers the best path to an American version of affordable and universal health coverage,” based on its evolution from a welfare program “to the nation’s primary program for expanding coverage to the uninsured,” its support from interest groups, its federal–state design, its innovation in managing vulnerable populations, and its size.

Heather Howard, a professor at Princeton and former health commissioner of New Jersey, reviewed the past, present, and future of state-based health reform: ”Our plea today here is that states can be important building blocks: …how do we create the conditions under which states can be positive contribut[or]s, and can be constructive in our reform efforts?”

Harold Pollack explored the “disability blind spot” in current policy and proposals. He suggest that “Universal coverage advocates really have to decide how much they want to become enmeshed in the daunting details of disability policy.”

Rebekah Gee, secretary of the Louisiana Department of Health, supported state leadership in reforms, but also raised the real-world issues of provider payment rates, network adequacy, and reliance on federal approvals for expansions. She also urged a focus on social determinants of health and drug pricing: “It’s unacceptable that a drug that prevents a death from an overdose from an opioid costs $4,500,” she said, “when it cost some $400 a few years ago.”

ACA-Based Options: Experts also looked at how to achieve an affordable, high-quality system with new public policy rather than a new public plan.

John Holahan, a fellow at the Urban institute, in addition to discussing how to improve the ACA, offered an option that, unlike others discussed, might not generate insurance company opposition: allowing individual market plans to adopt Medicare provider payment rates as a ceiling. Such legislation would, he explained, “allow more insurers to come in and would be an easier path to achieving the same objectives that people want from a public option.”

Peter Lee, CEO of Covered California, explained that because his state is approaching universal coverage, attention should turn to lowering costs and improving quality. In commenting on options discussed at the conference, he noted, “One of the advantages of a quote-unquote ‘public option’ is to ease the transitions of people between Medicaid and the Exchanges, which is a big issue. Forget the issue about… bare counties: there are good [reasons] for… having a valid, good competitor with plans that have historically not served low-income people.”

Ellen Montz, a senior fellow at TCF, focused on options for getting more people covered: she asked, “will more affordable options result in insurance coverage for all? The answer is, in most cases, no.” She reviewed passive, active, and hybrid options “which would not only improve coverage for individuals but also the competitiveness of markets.”

Kevin Patterson, CEO of Connect for Health Colorado, discussed the proposals from his own and his consumers’ perspective. When it comes to a public plan as a choice in the Marketplace, he urged all to carefully look at markets and options: “so if you’ve got a hammer and you need a screwdriver, [the hammer] may not be the best tool.”

By design, this conference did not yield a consensus on a particular way forward—but it did chart out issues to be resolved and the work to be done to help such a consensus emerge. As Mark Zuckerman, president of The Century Foundation, explained, “Today, we are kicking off a national discussion of what comes next with health reform.”

We will help shed light on these topics in the coming months. For example, The Century Foundation will dive deeper into the ways the options above differ, examining in greater depth those highlighted in this chart.

We expect the window for health care reform and expansion will open once again, potentially sooner rather than later. We will continue to work to make sure that, when it does, we are ready.